demonstrativo de pagamento - tratamento...
TRANSCRIPT
20 – Número da Carteira
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
21 -Nome do Beneficiário
Dados do Prestador
Dados do Pagamento
Demais débitos / créditos por Data de Pagamento
|___|___|___|___|___|___|___|___|,|___|___|
T Geral Pagamento49 - Valor Total Franquia por Data de Pagamento (R$)
|___|___|___|___|___|___|___|___|,|___|___|
48 - Valor Total Glosa por Data de Pagamento (R$)
|___|___|___|___|___|___|___|___|,|___|___|
Total Geral por Data de Pagamento
|___|___|___|___|___|___|___|___|,|___|___|
14-Número do lote
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40 - Valor Total Liberado Guia (R$)
|___|___|___|___|___|___|___|___|,|___|___|
50 - Valor Total Liberado por Data de Pagamento(R$)
|___|___|___|___|___|___|___|___|,|___|___|
Total da Guia
22 -Tabela 23 - Código do Procedimento 24 - Descrição 25-Dente/Região 26-Face 27-Data de Realização 28-Qtde 29-Valor Informado(R$) 30-Valor Processado (R$) 31-Valor Glosa/Estorno (R$)32- Valor Franquia( R$) 33-Valor Liberado (R$) 34-Código da Glosa
01- |___|___| |___|___|___|___|___|___|___|___|___|___| ____________ _______________________ |___|___|___|___| |___|___|___|___|___| |___|___/___|___/___|___|___|___| |___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|
02- |___|___| |___|___|___|___|___|___|___|___|___|___| ____________ _______________________ |___|___|___|___| |___|___|___|___|___| |___|___/___|___/___|___|___|___| |___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|
03- |___|___| |___|___|___|___|___|___|___|___|___|___| ____________ _______________________ |___|___|___|___| |___|___|___|___|___| |___|___/___|___/___|___|___|___| |___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|
8- Nome do Contratado 9 - CPF / CNPJ Contratado
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
37 - Valor Total Processado Guia (R$)
|___|___|___|___|___|___|___|___|,|___|___|
38 - Valor Total Glosa Guia (R$)
|___|___|___|___|___|___|___|___|,|___|___|
15-Número do Protocolo
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7 - Código na Operadora
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39 - Valor Total Franquia Guia (R$)
|___|___|___|___|___|___|___|___|,|___|___|
51-Indicação 54-Valor
|___| |___|___| ___________________________________________________________________________________________________ |___|___|___|___|___|___|,|___|___|
|___| |___|___| ___________________________________________________________________________________________________ |___|___|___|___|___|___|,|___|___|
47 - Valor Total Processado por Data de Pagamento (R$)
|___|___|___|___|___|___|___|___|,|___|___|
70 - Observação
36- Valor Total Informado Guia (R$)
|___|___|___|___|___|___|___|___|,|___|___|
35-Observação / Justificativa
16-Número da guia no prestador
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10 – Data do Pagamento
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11-Banco
|___|___|___|___|
12-Agência
|___|___|___|___|___|___|___|
13-Conta
|___|___|___|___|___|___|___ |___|___|___|___|___|___|___ |___|___|___|___|___|___|
Demais débitos / créditos do Demonstrativo
69 - Valor Final a Receber (R$)
|___|___|___|___|___|___|___|___|,|___|___|
Total Geral do Demonstrativo
63-Indicação 64-Código do débito/crédito 65-Descrição do débito/crédito 66-Valor|___| |___|___| ___________________________________________________________________________________________________ |___|___|___|___|___|___|,|___|___|
|___| |___|___| ___________________________________________________________________________________________________ |___|___|___|___|___|___|,|___|___|
Total do Demonstrativo61 - Valor Total Franquia (R$)
|___|___|___|___|___|___|___|___|,|___|___|
60 - Valor Total Glosa (R$)
|___|___|___|___|___|___|___|___|,|___|___|
58 - Valor Total Informado (R$)
|___|___|___|___|___|___|___|___|,|___|___|
62 - Valor Total Liberado (R$)
|___|___|___|___|___|___|___|___|,|___|___|
59 - Valor Total Processado (R$)
|___|___|___|___|___|___|___|___|,|___|___|
56 - Valor Total de Demais Créditos por Data de Pagamento (R$)
|___|___|___|___|___|___|___|___|,|___|___|
55 - Valor Total de Demais Débitos por Data de Pagamento (R$)
|___|___|___|___|___|___|___|___|,|___|___|
68 - Valor Total de Demais Créditos(R$)
|___|___|___|___|___|___|___|___|,|___|___|
67 - Valor Total de Demais Débitos(R$)
|___|___|___|___|___|___|___|___|,|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
18-Recurso
|___|
45 - Valor Total Liberado Protocolo (R$)
|___|___|___|___|___|___|___|___|,|___|___|
Total do Protocolo
42 - Valor Total Processado Protocolo (R$)
|___|___|___|___|___|___|___|___|,|___|___|
43 - Valor Total Glosa Protocolo (R$)
|___|___|___|___|___|___|___|___|,|___|___|
44 - Valor Total Franquia Protocolo (R$)
|___|___|___|___|___|___|___|___|,|___|___|
41- Valor Total Informado Protocolo (R$)
|___|___|___|___|___|___|___|___|,|___|___|
Dados da Guia
Dados do Protocolo
1 - Registro ANS
35.766-93 - Nome da Operadora
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6 - Data de Fim do Processamento
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2- Nº Guia no PrestadorDEMONSTRATIVO DE PAGAMENTO - TRATAMENTO ODONTOLÓGICO